Urology Coding Alert

How would you report this procedure?

Test your operative report interpretation skills with this case study from a Urology Coding Alert subscriber in Alabama.

Operative Procedure: The patient was brought to the operating room with IV fluids running and was placed in the dorsal lithotomy position following induction of general anesthesia. The skin over the lower abdomen, genitalia, perineum and upper thighs was prepared with chlorhexidine. The area is draped in a sterile fashion. The urethral meatus was dilated to 30-French using VanBuren sounds, still unable to grasp and extract the impacted distal urethral calculus. A cystoscope was inserted into the urethra. The stone was manipulated back into the more spacious bulbar urethra. The 550 micron Holmium laser fiber was advanced via the scope and was used to sequentially fragment the stone into easily passable or basket extractable fragments at a power of 6.4 watts. After fragmentation a Segura mini basket was used to extract larger fragments leaving very small fragments to pass spontaneously.

The scope was then advanced to the level of the prostatic urethra where three further similar size stones were noted to be eroding through the prostatic urethral mucosa posteriorly and represented threats to incur the same problem with a non-passable stone migrating down to the distal urethra. The Holmium laser fiber was re-advanced. The three prostatic stone were completely unroofed and then were sequentially fragmented with larger fragments extracted and very small fragments left to pass spontaneously.

A 7-french ureteroscope was then advanced per urethra to the bladder and then on into the intramural tunnel of the left ureter to evaluate hydronephrosis of unclear etiology. A 1 cm benign papilloma was identified 3 or 4 cm up the ureter from the ureteral orifice which appeared to be the only explanation for obstruction of hydronephrosis. The 350 micron Holmium laser fiber was advanced via the working port of the ureteroscope, and this lesion was ablated completely to restore normal caliber of the distal ureter. The scope was advanced up the full length of the ureter with no other abnormalities identified. 

As the ureteroscope was being removed, it was noted that there was significant bleeding from prostatic varices over the surface of the median lobe apparently induced by the multiple instrumentations in the area. I felt it was important to control this by fulguration to prevent postoperative bleeding and possible clot retention. The ureteroscope was removed. A 27-French continuous flow resectoscope was inserted and the bleeding from the median lobe surface was fulgurated and controlled. Instruments were removed. A 20-Frence catheter was inserted with 10 mL in the balloon irrigation through the catheter was clear. The catheter was placed to leg bag drainage and the procedure was completed.

How would you code this procedure?

Answer: You should report the following codes for this case:

• Report 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [over 2.5 cm]) for the fragmentation of the urethral and multiple prostatic calculi. Attach diagnostic codes 594.2 (Calculus in urethra) and 602.0 (Calculus of prostate).
• Report 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion) for the laser ablation of the ureteral polyp, with the diagnosis 593.89 (Other specified disorders of kidney and ureter... ureteral polyp...) attached.
• Report 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for the fulguration of the prostatic floor varices. Use ICD-9 code 456.8 (Varices of other sites) for the diagnosis of prostatic varices.

Bonus: Want your complicated operative report featured in Code This!? Send it to editor, Leesa A. Israel, at leesai@codinginstitute.com.